1609965573 NPI number — MRS. JILL KATHLEEN FLEAGLE MPC, LPC

Table of content: MRS. JILL KATHLEEN FLEAGLE MPC, LPC (NPI 1609965573)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609965573 NPI number — MRS. JILL KATHLEEN FLEAGLE MPC, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FLEAGLE
Provider First Name:
JILL
Provider Middle Name:
KATHLEEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MPC, LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609965573
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1520 ROCK RUN DRIVE SUITE 30
Provider Second Line Business Mailing Address:
CROSSROADS A COUNSELING AND CARE CENTER
Provider Business Mailing Address City Name:
CREST HILL
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60435-3153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-741-3009
Provider Business Mailing Address Fax Number:
815-741-8322

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1520 ROCK RUN DRIVE
Provider Second Line Business Practice Location Address:
SUITE 30 A
Provider Business Practice Location Address City Name:
CREST HILL
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60435-3153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-741-3009
Provider Business Practice Location Address Fax Number:
815-741-8322
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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